Classification Of Otitis media
1-suppurative = acute suppurative otitis media {ASOM}
Chronic suppurative otitis media{CSOM}
2-non-suppurative otitis media=acute [secrtory otitis
media]
Chronic [otitis media with
effusion] 3-
spesific otitis media=tuberculous otitis media
Syphilitic otitis media
4-adhisive otitis media {tympanosclerosis}
Chronic suppurative otitis media :-
Definition= Its chronic inflammatory processes in the
middle ear claft which have commone symptoms as long
standing painless aural discharge and some degree of
deafness they are grouped in to two main clinicale types
Tubotympanic {safe type} and Atticoantral {un safe type}
or dangerous type .
Pathology of chronic supp. Otitis media :-
1-tubotympanic (safe type): The inflammatory reaction
limited to mucosa of the middle ear claft , theres no bony
erosion of the middle ear claft with central type of
tympanic membaren perforation
2-Atticoantral (unsafe type) :The inflammatory reaction
extended via preostiome of the bone lead to bony erosion
of the tymporal bone and to the vital stracture around
middle ear claft , the T.M perforation is marginal type or
attic type , theres one or two important pathology can be
found granulation tissue with or without cholesteatoma
Cholesteatoma:- Its skin within middle ear claft , its not
tumour but usually form a cystic mass and the keratin
within the cyst is continuosly desqumated to form
central mass and the basal layer of the skin on the outside
of cholesteatoma sac .
Types of cholesteatoma : 1-congenital type
2-primary acquired type
3-secondary acquired type
Thiories of pathogenesis of acquired type are :-
1-Congenital cell rests , not commonly accepted but we
are suspected when see chol. Behind normal T.M.
2-Metaplasia , of the middle ear mucosa due to chronic
irritation
3-Invasion , most accepted theory so the skin from the
meatal wall of the outer drum surface invade middle ear
via posterior marginal perforation or attic perforation .
4-Immigration , the basal cell of germinal layer of skin
invade the submucosal connective tissue of middle ear and
that preduce chol . sac .
5-Invagination , the chronic negative middle ear pressure
forming retraction pocket of the drum lead to
accumulation of desqumated skin cell in side the pocket
lead to chol . formation .
Clinical picture of CSOM :-
The principal symptoms of CSOM are chronic purulent
otorrhoea coming from perforated drum or retracted
pocket of the drum , Deafness mostly conductive type ,
those symtoms quantity and quality depand on the type of
CSOM (safe or unsafe)
Safe CSOM the otorrhoea is more mucoid and less likely to
be offensive, but when suppuration is of unsafe type the
pus is scanty in amount , thick in consistency and foul
smell .
The deafness of safe type is mild to moderate conductive
deafness but in unsafe CSOM the deafness more profound
due to may be association with erosion of ossicles with or
without sensory neural deafness .
The change in the character of the discharge as increase in
amount , became foul smell , blood-staining , appearance
of aural polyp , otalgia or headach and vertigo often
indicate complication of CSOM need urgent management .
Treatment of CSOM =
Aim of treatment:-1-Arrest the disease .
2-Recovery of ear function .
Medical treatment ofCSOM:-
The degeneration , destruction and fibrosis are processes
with chronic infection , together with granuloma and
polyp formation lead to be more resistant to the topical
and paranteral medication , which mostly used in safe
type of CSOM .
The local application of antibiotic is unsuitable for those
with
1-complication .
2-chlesteatoma .
3-aural polyp or granulation tissue obstructing the ext .
meatus
The local treatment usually started with aural toilet by
suction or dry mopping , the ear drops should be applied
by the displacement method ( pushing the tragus of the
ear inside ext
Aud . canal when its filled with drops) .
The ear drop mostly contan antibiotic agenst gram
negative micro-organesime as garamycin with steroid and
antiseptic (spirit).
Systemic antibiotic , mostly used garamycin , claforain and
flagyl(for anaerobic)
Surgical treatment :-mostly used with
1-unsafe type of CSOM .
2-failure of medical treatment .
3-presence of aural polyp , granulation tissue and
cholesteatoma .
Aim of surgery : 1-To render the disease more safe by
removing necrotic bone , polyp , granulation tissue ,
cholesteatoma if present to prevent extension of the
disease to vital structures.
2-Prevent furether deterioration of ear
function .
3-To stop ear discharge permanently .
4-To treat the complication of CSOM .
The surgical treatment ranging from aural polypectomy
to different types of mastoid and other middle ear
surgery (mastoid exploration with middle ear
reconstructive surgery ) .
Types of mastoid surgery :-
1-Cortical mastoidectomy (simple mastoidectomy)
exploration of mastoid air cells via post . auricular incision
.
2-Radical mastoidectomy - When the disease of CSOM is
extensive (removal of all middle ear structure a parte from
stapes, exploration and exteriorization of mastoid air cells
via wide meatoplasty) .
3-Modified radical mastoidectomy(removal of diseased
tissue with conservation of normal middle ear tissue to
preserve ear function by forgather reconstructive middle
ear surgery .
The mastoid surgery is to converted closed disease area with high
incidence of complication to open cavity which easy to follow up .